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Debate: Limiting public medical care for smokers

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Should smokers receive limited or no public medical care?

Background and context

High profile and costly court settlements from tobacco companies -- in the US particularly -- have highlighted the (almost) universal acceptance that smoking causes many grave and fatal medical conditions. Epidemiological studies have identified links between smoking and a wide range of medical conditions, from heart disease to male impotence. Some estimates place up to 85% of cases of chronic obstructive lung disease as very probably/causally linked to tobacco consumption, or give even higher rates of linkage for heart disease or lung cancer. Smokers choose to smoke, knowing in the vast majority of cases that the activity is harmful. You might argue that they effectively choose the associated medical problems. Should the state have to take responsibility for the medical burden created by such conscious self-abuse? Those who contract lung cancer have only a 10% chance of surviving for five years. In this period they may require intensive care, expensive both financially and in terms of scarce resources. Is smoking an informed decision effectively to undermine the state’s capacity to provide healthcare for citizens, including more prudent ones? If it is, should making this choice be taken as in some way reducing, or even giving up the right to these services? These questions underpin this debate, and cut to the centre of ideas of rights and obligations between states and citizens. N.B.1 This is a complex policy debate. To provide a greater degree of focus, many of the examples below is UK based. However, the principles which the examples illustrate should be relevant in every country. N.B. 2 In addition to the books recommended, more history of thought/philosophical study might include examination of: utilitarianism e.g. Jeremy Bentham, or James Mill; rational choice sociology e.g. in Social Theory by Patrick Baert (introduction), or James Coleman, or Gary Becker; modern ‘risk society’ e.g. Ulrich Beck, and citizenship e.g. Bryan Turner.

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Argument #1

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Yes

Rights and Obligations – There is a clear similarity between being required to behave in certain ways to receive other forms of state assistance (welfare), and making similar active efforts to preserve your health. The right to unemployment welfare payments depends on having to make some effort to seek employment (in most developed countries). You may choose not to seek work, but then it is no longer the duty of the state to subsidise you. It is therefore completely consistent to say such an incentive system should exist with regards to another essential – your health. Indeed, it is probably fairer than the denial of welfare payments, as truly nobody is forced to smoke. By contrast, those pressured by circumstances beyond their control into homelessness, undiagnosed depressions etc. –- may have legitimate reasons for failing to attend job interviews, etc.

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No

If we consider what is best for society as a whole, it is clear that keeping people healthy even in spite of their efforts to the contrary is worthwhile. First, because not to do so does not promote a caring society. Rather, it encourages one that turns away from millions of people, merely for making one perfectly legal, if ill-advised lifestyle choice. The assumption of freedom of choice is itself also questionable; consider the effective force of teen peer pressure, the increased likelihood that children with parents who smoke will also smoke, or other stressful conditions. Economically, the healthcare of the nation is important for maintaining a productive workforce. Do we really want to lose otherwise functional members of the workforce the first time they contract an aggravated throat infection and cannot afford, or delay for financial reasons, a simple course of antibiotics? If we now consider the nature of healthcare, is clear that in contrast to welfare, hospitals necessarily have to treat the results of reckless behaviour all the time. ‘Accident and Emergency’ departments, the ‘Emergency Room’ etc. -- are daily stuffed with arms broken whilst drunk, eyes taken out by the misuse of fireworks, and even injuries sustained in the course of criminal acts. Drawing any line, at which someone’s actions remove from the state a medical duty of care to that person, is arbitrary. What about drug users (criminals in most countries)? What about those who practice sadomasochism (criminals in many countries) -- another act that necessarily entails injury? The way that healthcare actually works makes this policy inconsistent, and thus unjustifiable.

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Argument #2

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Yes

Resource Availability and Likely Effectiveness of Treatment – Different countries have different degrees of capacity or financial shortfall in their health systems. In either case, smokers contribute disproportionately to this problem. Allowing smokers to take scarce beds or organs needed for transplants -- that could otherwise go to those suffering from genuine misfortunes -- is a social injustice. People suffer massive discomfort and even die whilst on waiting lists for operations. Smokers consume selfishly. In the UK it is estimated that up to 9,500 beds are blocked daily by smokers, and that up to eight million doctor consultations are required on their behalf each year. While it is true that smokers often pay a lot of tax for their habit, taxation is necessary as a deterrent. Moreover, the core point again is about free choice. Smokers choose to buy tobacco and pay tax; it is not forced upon them. Tax is an unreliable indicator of worthiness of state help. The rich are disproportionate contributors to healthcare via income tax, but few suggest they ought to be entitled to a better service from the state than anybody else. On the other hand, in no countries are the rich forced to use private healthcare and entirely denied state services under any and all circumstances. We accept that nobody chooses either to be rich but always or suddenly ill, or to be poor but always healthy. But everyone who chooses to smoke -- chooses to smoke.

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No

Rejecting and discrediting the link between the tax on tobacco and healthcare costs would politicize the sleeping issue of ‘smokers’ rights’, probably vigorously among those who have smoked for many years, and feel they are due the returns from their inflated investment in the system. The UK currently takes 60% of the cost of cigarettes in tax. Smokers are net contributors to the treasury to the tune of around ?8Bn. Considering rises in the numbers smoking in some sections of society -- young women in particular -- nobody is going to buy the ‘effective deterrent’ argument. Duty would thus be much harder to justify where smokers do not even get healthcare for their money. This means a potential drop in cigarette prices. This means potentially more smokers. At worst, this means more of a strain on state healthcare resources, as the private sector expands to accommodate more smokers and eats up resources. In the best-case scenario, it means an unstable balancing act between the overstretched state, disgruntled smokers, the loss of tobacco tax revenue, the potential for greater numbers smoking, and a shift towards private or outsourced medical care. It would be reckless to create such a house of cards. The persistence of smoking in spite of known risks, in spite of tax, implies that the temptations of tobacco would be too strong. Healthcare would adjust to accommodate tobacco’s appeal, not the reverse.

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Argument #3

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Yes

Operations and treatment are actually less likely even to work when they are provided for smokers. First, some operations are less successful where smoking has caused the problem, e.g. heart bypasses. Second, since serious smoking related illnesses often occur in combination, operations are complicated to the point of probable failure. For instance, lung cancer is often coupled with emphysema. Treating both at the same time is massively problematic. Thus treatment -- not to mention research -- resources are being wasted trying to improve the survival rates of people who bring these dual horrors upon themselves.

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No

Although everyone accepts that tobacco consumption is linked to a number of illnesses, none of these illnesses are only caused by smoking. So even in the case of a heavy smoker, we cannot be sure that their, e.g. lung cancer, definitely resulted from smoking rather than some other cause. Among lighter smokers, or former smokers who gave up before illness was diagnosed, making this link is even harder. Denying medical treatment to people by treating these possibilities as certainties is very unfair, and will lead to great inconsistencies and hard cases

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Argument #4

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Yes

Deterrent – Governments should do everything they can to discourage smoking, rather than accepting it as an inevitability. Even if taxes could not be maintained against popular pressure to the contrary, the refusal of medical treatment to smokers would surely be a massive deterrent to current/potential smokers from continuing/starting the habit.

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No

People start smoking even though they know it is an expensive and (literally) malodorous habit, and that it will probably kill them. People then continue to smoke even as short-term use stains their teeth, causes them to be short of breath, and so-on. Deterrents do not work. Furthermore, if there were enough ill smokers to create a massive demand for private healthcare (which there would be) then the privatisation process would limit the deterrent value of this policy. From the point of view of potential smokers, healthcare costs might be higher in many years’ time, but not prohibitively so. Cigarette prices may be dropping anyway to compensate (as above); and having already decided to shorten one’s life considerably, these are really comparatively minor worries in the first place. Some deterrent.

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Argument #5

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Yes

Furthering Social Inequality? – More deprived socio-economic groups are more likely to smoke. This is probably because the financial deterrent is not large enough. Of all sections of society, the working classes should be the easiest to deter from smoking by economic means, given they have the least disposable income to spend on luxuries. Having to pay for healthcare as well as cigarettes would outweigh any culture of smoking. Further, even if the scale of the working class smoking problem is mostly due to cultural factors, it should be remembered the working classes are also more likely to use free public healthcare generally. First, because their standards of health are on average lower. Second, because the working classes are less likely to be able to afford private care. Therefore, it is they who suffer most from clogged up wards. Tarring all working class people with the same brush, and treating smokers like victims, means – once again – removing an effective reward/incentive system to encourage people not to smoke. Good, hard working people pay for the irresponsibility of smokers; this is unjust. Making good, hard working and poorer people bear the brunt of the problem, is even more unjust.

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No

This policy is as much about privatising healthcare for the poor as for smokers. Working class men are more likely to contract cancer. In the UK, they are four times more likely. This is not merely because they smoke more – although this is a problem in and of itself – it is also because their lifestyles expose them to more potential harms. This point fits in with the practical issues in point 6. Working class people who do not smoke would never choose to have their friends and family suffer. Further, the cost of treating them privately would be likely filter down to friends and family anyway.

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Argument #6

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Yes

Practical Issues -- This is primarily a debate about a principle. Practical hurdles are secondary to deciding what is it health services should achieve, and how they should achieve it in the first place. That said, there are realistic ways this policy could be carried out. Insurance companies already ask lots of health-related questions, often including whether their client is a smoker, when assessing life insurance premiums. In these cases, you are required to give details of your lifestyle by law. Of course, some people do not, however this is to be expected since no law is one hundred percent effective. Sanctions exist to discourage dishonest behaviour. A similar model could be put in place requiring a declaration of smoker status to the health authority. Indeed, many doctors already enquire about their patients’ smoking statuses on an informal basis. It is also particularly hard to lie about being a smoker for two reasons. First, other people inevitably see you smoking. This means an abundance of witnesses in the case of a disputate, and thus a disincentive to lie. Second, people require doctors to undertake detailed examinations for treatment purposes, thereby allowing them to see obvious outward signs of smoking: tar deposits, tar in cough, yellowed fingernails, etc. Clearly, there is a need to set guidelines for what is practicable and fair with regards to timetable issues and the types of treatment which would remain available to smokers. However, doctors and health services make these kinds of judgements all the time. In the UK, IVF is only provided to couples after extensive vetting of their appropriateness as parents, medically and socially. Likewise, the psychological impact of obesity, cosmetic disfigurations, etc are assessed before plastic surgery is paid for by the state.

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No

This policy is beset with huge practical obstacles. These are significant not merely because they undermine implementation, but because systemic flaws undermine the idea that healthcare rights are recognised on the same ‘fair’ bases for everyone – and this is the first principle of the proposition’s case. There are probably three main issues: First, the extent to which care is denied is questionable. Does the proposition model include denying palliative care? If it does, this literally means leaving people to suffer agonising pain in emergencies while they try to locate private prescription painkillers, if they can afford them. Further, does it include denying emergency procedures such as resuscitation in the case of a heart attack? If it does, where are patients supposed to go? Private emergency rooms are few and far between, or non-existent, in many countries – never mind private ambulances. Second, issues of timing are relevant to this debate. The proposition’s beloved system of social incentives is the first line of fire. In order to encourage smokers to stop smoking, the process needs to involve reactivating access to healthcare if smokers quit. But any cut-off point at which the right is re-activated will necessarily be arbitrary. Some studies have suggested that, for instance, teenagers do irreparable damage to their respiratory systems even if they stop smoking young. If all citizens make an informed decision to smoke, as the proposition argues, isn’t it the case that teenagers make an informed decision to do inordinate damage to their bodies? If it is, then why should there be an absolute cut-off point at which one reassumes healthcare rights? Should there be a relative scale? Wouldn’t this be impossible to construct on a scientific basis? Further on constructing fair systems scientifically, the major practical issue undermining this case is being sure the person is a smoker, especially if it is alleged that they were in the past rather than the present. Couldn't they have got their illness through, e.g. passive smoking or an industrial process?

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